Bilateral Lower Extremity Pain

1. Bilateral Lower Extremity Pain Kristina DeMatas, D.O. Sports Medicine Fellow Mayo Clinic Jacksonville 2/11/12

2. History • 35 yo female • Federal law enforcement officer & competitive power lifter • Noticed bilateral leg pain after a hard workout • Treated with massage and stretching for gastrocnemius muscle spasm by her Physical Therapist x 1 week

3. History Continued • 1 week later • Traveling from Georgia to Austin, TX • Felt fatigued and dehydrated from a strenuous workout • Slept the entire 5 hr flight • Upon standing she felt severe pain in her bilateral calves • Presented to the ER

4. Past Medical History • Past Medical Hx: GERD, Anxiety, hx of PFO  • Family Hx: Mother-end stage lung cancer, PE • Home medications: • Loestrin 24 (started 4 months ago) • Prozac 20mg daily • ASA 81mg daily • Allergies: PCN • Social Hx: single, non-smoker, no EtOH or drug abuse

5. Physical Exam • Gen: Young healthy female, NAD   • Vitals: BP 160/83, repeat 120/70, HR 86, RR 18, O2 sat 100% RA, wt 57.6 kg  • HEENT: WNL  • CV: S1, S2, regular rhythm, no murmur  • Lungs: CTA bilaterally • Extremities: negative for swelling or discoloration, positive for bilateral calf tenderness with palpation • MSK: Knee and ankle ROM WNL, no joint effusion • Neuro: WNL

6. Questions on History or Physical Exam? ?

7. Differential Diagnosis 1. Gastrocnemius/Soleus strain or tear   2. Achilles tendonitis 3. DVT   4. Rhabdomyolysis  5. Ruptured Baker’s cyst 6. Calf hematoma 7. Compartment Syndrome 8. Cellulitis

8. Questions?

9. Tests and Results • CBC, BMP WNL • BNP WNL • TSH WNL • INR-1.03  • CK- 87  • US-DVT right popliteal vein and peroneal vein 

10. Final Working Diagnosis DVT right popliteal and peroneal vein

11. Treatment and Outcomes • Admitted to telemetry  • Started on Lovenox and Coumadin • Discharged the next day • Oral contraception discontinued • Hypercoagulable workup negative

12. Treatment and Outcomes • 1 month after Dx • Presented for clearance and recommendations about activity while on Coumadin • Demoted to a desk job, gun confiscated, told she was unable to drive a vehicle at work  • Anxious and tearful about her lifestyle changes  • Currently taking 12.5-15 mg of Coumadin daily. INR therapeutic  

13. Treatment and Outcomes • Gradual return to activity but at a low level • No heavy weights while on coumadin • Watch for signs of bleeding • Cleared to operate a motor vehicle, maintain firearms proficiency, teach officer response tactics -including searching, defense, and weapons confiscation  • Refrain from activity that causes head, body or extremity blows  • Restrict all exercise if INR 4 or higher. If 3.5 - 4 should only do extremely light exercise

14. Treatment and Outcomes • Repeat B/L US 1 month after diagnosis showed resolution of right popliteal DVT, positive for left peroneal vein DVT   • Complained of significant side effects from Coumadin including muscle aches and pain in areas of previous injury • Rheumatologic workup negative   • Coumadin discontinued   • Started on Lovenox 60mg q12   • Anticoagulation for 6 months 

15. Thank You

16. Are Athletes at risk for DVT?Return to Play Guidelines? • Risk Factors • Orthopedic trauma • Postinjury immobilization • Frequent & Prolonged travel • Hemoconcentration • No consensus that elite athletes are at higher risk for DVT • No return to play guidelines currently exist for athletes with venous thrombosis • No RCT or large cohort studies documenting safe timing of exercise